Myelopathy in a 25 yo

by

Michael H. Rivner, M.D.

25 yo black male who was in good health until 3 weeks ago when he noted cramping in the left leg.  This progressed to clumsiness  and numbness.  These symptoms then progressed to the right lower extremity and then the upper extremity.  The patient was seen at several express care locations and was dismissed as hysterical.  He was seen by a chiropractor who gave him an adjustment which he stated helped the cramping.  He came to our emergency room because his weakness continued to progress until the point that he had difficulty walking.  He denied bowel or bladder incontinence and was able to get erections.

On exam he did not have any significant pain in either his neck or low back.  He had an unsteady gait.  He had a left sided sensory level in which sensation was present but less intense below T4.  On the right side he had hyperpathia below T5.  He had reduced proprioception and vibratory sensation in the lower extermities bilaterally.  His lower extremity tone was increased.  His strength was 4/5 in the lower extremity and normal in the uppers.  He had clumsiness in the lower extremities and the left upper extremity.  His reflexes were 4+ in the lower extremities with bilateral ankle clonus.  Reflexes were 3+ in the upper extremities.  A bilateral Hoffmans sign was seen.  Cranial nerves were normal with the exception of a mild left lateral gaze defect.

Chest Xray which is displayed below showed hilar adenopathy.  Liver enzymes were slightly elevated.  The patient denied any significant alcohol or drug abuse.  MRI shown below shows an intrinsic cord lesion.  There is also a C4 disk that is impinging the cord.  MRI of head was normal as was the plain C-spine films.

It is my impression that this patient has sarcoid.  The patient was given decadron 4mg on admission and prednisone 60mg a day which has produced mild improvement in the symptoms since admission--1 day ago.  I have an angiotensin converting enzyme pending and will probably look at the liver with a ct scan.  Does anyone think this is anything else? Would anyone do anything about the disk?

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Revised 9/3/2000

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